Advanced stage IV emphysema represents a significant burden to patients and their families. It is characterized by disabling breathlessness and unexpected prolonged survival. This results in distressingly poor quality of life resulting from dynamic hyperinflation on exercise and recurrent infective exacerbations. Consequently, many patients seek surgical intervention in the form of lung transplantation and/or volume reduction surgery. Surgical therapy is fraught with difficulty and is particularly dependent on preconditioning with pulmonary rehabilitation. Therefore, pulmonary rehabilitation is the foundation of management on which all other therapies are built at this phase of emphysema.